This paper reports the research results of a group of researchers from the Cincinatti Sportsmedicine and Orthopaedic Center. The research relates to a consecutive group of patients (443 knees) with cruciate ligament reconstruction - alone or combined with associated procedures (about 50:50). Half of these patients were subject to a 'delayed' rehabilitation programme (the more traditional approach) while the other half were subject to a 'progressive' rehabilitation programme (the more modern approach). In all of them, though, if the patient was found to be progressing inadequately with mobilisation of the knee then the team 'intervened' early with the kind of rehabilitation or surgical programme relevant to arthrofibrosis.
What the team was appraising here was the question - "To what extent is early intervention really significant in minimising the complication of limitation of motion, and also how significant is the early rehabilitation programme?" This work followed previous studies looking at the effect of both the complexity of the ligament problem and the effect of the speed of the rehabilitation programme, and in which they had already identified that about 10% of patients needed intervention for problems with limitation of knee motion, of whom 1% required re-operation for this problem.
The Study
Patient Series
By following a consecutive series of patients one eliminates considerable bias in choosing the population group. 445 consecutive patients were followed, but two were eliminated from the study (one patient died of unrelated problems, and one already had arthrofibrosis before the cruciate surgery was undertaken). Thus 443 patients were entered into the study (443 knees). 294 were men, and 149 were women, and the average age was 29 ((range 14 to 62). Approximately two-thirds of cruciate tears were 'chronic', ie the surgery was being performed at least 12 weeks after the injury.
Surgery
All of the reconstructions were done using patellar-tendon autograft. A tourniquet was used only briefly for the initial graft harvest. Femoral notchplasty (widening the bony roof over the cruciates) was performed where indicated to allow the graft adequate room to function.
Results and Discussion
Both the progressive and delayed programmes showed an extremely low incidence of arthrofibrosis and re-operation. Only 0.7% of the 443 entering the study had such limitation of motion as to require re-operation. 98% of the 443 regained normal ROM, and no knee (0%) developed permanent arthrofibrosis.
The authors point out that in the early weeks after surgery any arthrofibrosis is transient if correctly managed and it should be successfully resolved with a programme like that described in this paper. The authors feel, though, that after 1-3 months arthrofibrosis is frequently established - but thay nonetheless emphasise that significant motion gains can still be made with appropriate surgery and further rehabilitation.
